Tobacco control policy should be based on science, not misconceptions

Despite hype to the contrary, science has nothing to do with tobacco-control policy. The goal of a “tobacco-free-society” that condemns all use of non-pharmaceutical nicotine products regardless of addictiveness or risk, considers the “tobacco industry” to be the enemy, and labels smoking a disease, is based on long-standing perceptions and beliefs within the tobacco-control community.

Scientific research based on these beliefs is done for two purposes. The first is to guide policies in support of an abstinence-only approach; the second is to document the risks and hazards presented by tobacco-related products. Research into potential personal and public health benefits of alternative products is left to the manufacturers, with the expectation that any such benefit would lead to licensure of those products as drugs. As seen by the tobacco-control community, reduced risk is not a benefit, since it still represents preventable risk. Moreover, the community believes that marketing a product as “reduced risk” would recruit teens and other non-smokers to tobacco use, who would then transition to cigarettes for a bigger and faster nicotine hit.

Prior to the advent of the modern e-cigarette and related vapor devices, no one involved in either tobacco control or the tobacco industry ever imagined the possibility of a product that could satisfy the urge to smoke for smokers while reducing the risk of potentially fatal cigarette-related illness by 95 percent or more, and do so without recruiting kids. Not only have e-cigarettes done that, they also appear to divert teens away from cigarettes.

E-cigarettes differ from the pharmaceutical nicotine gums, patches and lozenges in that they satisfy a smoker’s urge to smoke. They differ from the low-risk smokeless tobacco products, long on the American market, in their attractiveness to smokers. They are also superior to pharmaceutical nicotine products in that the variety of flavors can turn ex-smokers away from the association of tobacco flavors with cigarettes. Thus, if and when the urge to smoke returns, they return to e-cigarettes, not to cigarettes.

This should be cause for celebration, but those in the tobacco-control camp are trapped by history and tradition. With the reframing of tobacco control as a public health endeavor intended to prevent disease and death came a moral crusade against the tobacco industry, which was ostensibly intent on getting our children addicted to a deadly substance, and doing so for profit. Since cigarettes — the deadliest tobacco products — have long dominated Western markets, and since no tobacco-related product can be considered totally risk-free, the goal of the tobacco-control enterprise was set as “a tobacco-free society.”

Reversing this goal will not be easy. The advent of the e-cigarette poses a moral dilemma for the most stalwart advocates of tobacco control. Supporting the most effective harm-reduction products also means having to, at the very least, tacitly support those in “big” tobacco. However, tobacco harm-reduction programs and advocates have demonstrated that there are public health advocates, and tobacco industries are willing and able to collaborate in pursuit of shared public-health objectives. The industry is neither monolithic nor entirely evil. The secret to public-health progress will not be in opposing all things tobacco, but in sorting out the good guys from the nefarious ones within the industry.

All this could be resolved by changing the goal of the tobacco control enterprise from “a tobacco-free society” to “a smoke-free society,” which would be virtually free of tobacco-related disease and death. This is a step that tobacco-control authorities have, to date, been unwilling to put on the table for discussion for the reasons noted above.

There have been hopeful statements by Mitch Zeller, head of the Food and Drug Administration (FDA) Center for Tobacco Products, and Dr. Scott Gottlieb, newly appointed director of the FDA, recognizing the potential value of adding a tobacco harm-reduction component to tobacco-control programming. Unfortunately, to date they have taken very little action to reflect their statements. Meanwhile, FDA and the Center for Disease Control (CDC) continue to discourage use of e-cigarettes and smokeless tobacco products, and federal tobacco-control agencies continue to devise new initiatives aimed at what we know are lower-risk products.

At the same time, thousands of American teens begin smoking each day, and millions of adult smokers suffer and die from cigarette-related illness that could have been prevented by reconsidering long-standing tobacco-control policy in light of advances in our knowledge of e-cigarettes and tobacco harm reduction.

Just as digital photography has made photographic film obsolete for most uses, e-cigarettes and related vapor products may someday make cigarettes a thing of the past. Adding a tobacco harm-reduction component to tobacco-control programming could make cigarettes obsolete and, by so doing, drastically reduce tobacco-related illness and death.